OSDH Form 1061 "Lgc Documentation of Supervision" - Oklahoma

What Is ODH Form 1061?

This is a legal form that was released by the Oklahoma State Department of Health - a government authority operating within Oklahoma. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2021;
  • The latest edition provided by the Oklahoma State Department of Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of ODH Form 1061 by clicking the link below or browse more documents and templates provided by the Oklahoma State Department of Health.

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Download OSDH Form 1061 "Lgc Documentation of Supervision" - Oklahoma

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Oklahoma State Department of Health
Consumer Health Service
P
ROTECTIVE
Occupational Licensing
Licensed Genetic Counselors
H
EALTH
Mail: PO Box 268815, Oklahoma City, OK 73126-8815
Physical: 123 Robert S Kerr Ave, Oklahoma City, OK 73102
S
ERVICES
Phone: (405) 426-8250 // Fax: (405) 900-7557
Website:
http://chs.health.ok.gov
LGC DOCUMENTATION OF SUPERVISION
Note to supervisor: Information given on this form is for this twelve-month interval only. When the
evaluation form is completed, review it with your supervisee. The majority of complaints received in our office
involve dual relationships and breaches of confidentiality. Please emphasize these ethical considerations to your
supervisee.
Note to temporary licensee: If you are documenting experience at more than one setting or with more than one
supervisor, submit evaluations for each setting separately and submit more than one supervision agreement if
necessary.
Name of Temporary Licensee:
Name of Supervisor:
Name of Place of Supervision:
Address of Place of Supervision:
City, State, Zip:
Dates of supervision this twelve-month period:
From:
To:
Describe the types of patients seen by temporary licensee at the current setting:
Supervisor comments:
Oklahoma State Department of Health
ODH Form #1061
Protective Health Services
PAGE 1 OF 2
(Rev.10/21)
Oklahoma State Department of Health
Consumer Health Service
P
ROTECTIVE
Occupational Licensing
Licensed Genetic Counselors
H
EALTH
Mail: PO Box 268815, Oklahoma City, OK 73126-8815
Physical: 123 Robert S Kerr Ave, Oklahoma City, OK 73102
S
ERVICES
Phone: (405) 426-8250 // Fax: (405) 900-7557
Website:
http://chs.health.ok.gov
LGC DOCUMENTATION OF SUPERVISION
Note to supervisor: Information given on this form is for this twelve-month interval only. When the
evaluation form is completed, review it with your supervisee. The majority of complaints received in our office
involve dual relationships and breaches of confidentiality. Please emphasize these ethical considerations to your
supervisee.
Note to temporary licensee: If you are documenting experience at more than one setting or with more than one
supervisor, submit evaluations for each setting separately and submit more than one supervision agreement if
necessary.
Name of Temporary Licensee:
Name of Supervisor:
Name of Place of Supervision:
Address of Place of Supervision:
City, State, Zip:
Dates of supervision this twelve-month period:
From:
To:
Describe the types of patients seen by temporary licensee at the current setting:
Supervisor comments:
Oklahoma State Department of Health
ODH Form #1061
Protective Health Services
PAGE 1 OF 2
(Rev.10/21)
LGC DOCUMENTATION OF SUPERVISION LOG
(This page should always accompany the Documentation of Supervision Form)
Make copies of this page as needed.
Temporary Licensee’s Name (please print):
Supervisor’s Name (please print):
Date Supervision Agreement was approved by the Department:
WORK WEEK
DATE(S) MET
BEGINNING
WITH YOUR
COMMENTS
DATE:
SUPERVISOR
TEMPORARY LICENSEE'S SIGNATURE:
Date:
SUPERVISOR’S SIGNATURE:
Date:
Oklahoma State Department of Health
ODH Form #1061
(Rev. 10/21)
Protective Health Services
PAGE 2 OF 2
Page of 2